Long-term results of robotic-assisted nasopharyngectomy for recurrent nasopharyngeal carcinoma.

BACKGROUND: We have previously reported our early experience in robotic-assisted nasopharyngectomy. The current case series is a report of our experience in 33 robotic-assisted nasopharyngectomy. METHODS: Prospective series of patients who underwent robotic-assisted nasopharyngectomy for local recurrent nasopharyngeal carcinoma from January 2010 to March 2019. RESULTS: Thirty-one patients underwent robotic-assisted nasopharyngectomy with two additional second procedure for positive margin. Median age is 55 years (29-85). Twenty-five patients had rT1 disease and six patients had tumor invaded sphenoid floor (rT3). Median operative time was 227 min and median blood loss was 200 ml. The median follow-up period for all patients were 38 months. Four patients had local recurrence. Five-year local control rate, overall survival, and disease-free survival are 85.1%, 55.7%, and 69.1%, respectively. CONCLUSION: Robotic-assisted nasopharyngectomy for recurrent nasopharyngectomy was showed to have a high local control rate. The operating time was comparable to open surgery.

Surgical Treatment of Advanced Staged Hypopharyngeal Cancer.

It is not uncommon for patients with hypopharyngeal cancer to present at an advanced stage of disease. Surgical treatment provides a cure for the tumour with immediate relief from obstruction to the airway and the swallowing passage. Careful planning of surgery is important to ensure good outcome of treatment and prevent complications, some of which may be fatal. The shape of the hypopharynx resembles that of a funnel, with a wide circumference above in continuity with the oropharynx, and a small circumference below where it joins with the cervical oesophagus. As a result, while small tumours require the partial removal of the hypopharynx, large tumours, especially those involving the post-cricoid region, warrant a complete, circumferential pharyngectomy. For tumours that invade the cervical esophagus, transcervical approach is still feasible, and this is facilitated by the removal of the manubrium, allowing access to the tumour and resection with clear margins. In the presence of synchronous tumours lower down in the esophagus, pharyngo-laryngo-esophagectomy is indicated. Successful reconstruction of defects after tumour extirpation allows proper wound healing and early delivery of adjuvant radiotherapy. It is also important to ensure quick recovery of the long-term swallowing function. It ranges from the use of the soft tissue flap with skin island that is sutured as a patch to the remnants of the pharyngeal mucosa, to the use of a visceral flap, such as the free jejunal flap, to repair the circumferential pharyngectomy defects. The treatment protocol is personalized according to the extent of the tumour and the characteristics of the patients.

Endoscopic surgery for malignant sinonasal tumours: an eighteen year experience.

INTRODUCTION: Curative resection of malignant tumours of the skull base is increasingly undertaken endoscopically. Hitherto the diverse histology, rarity and long natural history have made it difficult to accrue statistically robust cohorts for comparison with conventional craniofacial resection. It is now possible to make such a comparison in a large personal cohort. METHOD: Data on all cases of sinonasal malignancy undergoing endoscopic resection with curative intent over an eighteen year period were collected prospectively and analysed for survival and prognostic factors. RESULTS: There were 140 cases, 68 men and 72 women, aged 20-92 years (mean 63 yrs). Follow-up ranged from 6-184 months (mean 60 months). Eighteen different histopathologies were represented with olfactory neuroblastoma (36), malignant melanoma (33) and adenocarcinoma (19) being the commonest. Additional radiotherapy was given in 95 cases and chemotherapy in 49. Overall survival is 84% at 5 years and 69% at 10 years. Overall disease-free survival was 77% at 5 years and 56% at ten. Overall and disease-free survival at 5 (and 10) years is, respectively, 97% and 90% for olfactory neuroblastoma, 79% and 68% for adenocarcinoma and 56% and 39% for malignant melanoma. CONCLUSION: These results show that endoscopic resection is an alternative to conventional craniofacial resection in selected cases.

Salvage surgery for nasopharyngeal cancer.

Nasopharyngeal carcinoma (NPC) is a special type of head and neck cancer with a widely variable geographical variation in incidence. The central location of the tumor inside the head coupled with the radiosensitivity of the tumor to radiation made radiation therapy the first choice in primary treatment of NPC. Advances in radiotherapy and chemotherapy have markedly improved the local control of NPC. Unfortunately, a small but significant number of patients still suffered from loco-regional failures that would be amenable to re-treatment. Traditional form of retreatment was to employ a second course of radiation. The efficacy of re-irradiation to treat local of regional recurrent NPC has been suboptimal. Moreover, the local tissue had already received a high dose of radiation and the second radiation could result in radiation toxicities to the local tissue, leading to significant complications. Surgical salvage, on the other hand, could spare the patients from complications of re-treatment. Due to the difficult access of the nasopharynx, various surgical approaches had been devised for nasopharyngectomy. The maxillary swing approach had the largest published experience with over 300 cases from various centers. In the recent decade, the endoscopic approach with or without robotic assistance had gained popularity for resecting small, centrally located recurrences. This minimally invasive approach further reduced the morbidity for treating locally recurrent NPC. Nodal recurrences had been a rare entity after the introduction of modern radiotherapy technique and concurrent chemotherapy. Treatment of nodal failure with second radiation has dismal results. Surgical removal of the lymph node harboring the recurrence should be in the form of a formal radical neck dissection. In cases of extensive nodal recurrence where microscopic disease may be present after a formal neck dissection, additional radiotherapy can be delivered with after-loading brachytherapy. Surgical treatment played a definitive role in salvage of loco-regional failures of nasopharyngeal carcinoma.

Early results of robotic assisted nasopharyngectomy for recurrent nasopharyngeal carcinoma.

BACKGROUND: Minimally invasive nasopharyngectomy with the da Vinci surgical robot has been shown to be a feasible operation for salvage of recurrent nasopharyngeal carcinoma. The current case series presents the early results of robotic nasopharyngectomy. METHODS: We conducted a prospective series of patients who underwent robotic nasopharyngectomy for recurrent nasopharyngeal carcinoma in a single institution. RESULTS: Twelve patients underwent robotic nasopharyngectomy. The median operating time was 225 minutes. Median follow-up time was 23.8 months. Nine patients had clear resection margins, 2 patients had close margins, and 1 patient had positive margin. Two patients developed local recurrence and 1 patient had distant metastasis. Two patients in the cohort died of unrelated causes. The 2-year local control rate was 86%. The 2-year overall survival and disease-free survival was 83% and 61%, respectively. CONCLUSION: Early results of robotic nasopharyngectomy showed a high local control rate. The operating time was comparable to open surgery and morbidities were low.

Salvage surgery for recurrent carcinoma of the cervical esophagus postesophagectomy.

BACKGROUND: Management of cervical esophageal tumor postesophagectomy is mainly palliative because of inadequate exposure of tumor in the cervicothoracic region. In this study, we propose a means of cure for these patients. METHODS: Between January 2003 and June 2013, 6 patients underwent curative pharyngolaryngectomy and completion cervical esophagectomy via manubrial resection. Operative outcomes were analyzed and compared with a historical cohort who received palliative therapy. RESULTS: One patient required prolonged hospital stay for pneumonia, resulting in a median hospital stay of 30 days (range, 21-55 days). All patients resumed oral feeding at a mean of 15.2 days (range, 14-19 days). Tracheostoma stenosis was noted in 2 patients. One patient developed nodal recurrence, another with distant metastasis, resulting in a median disease-free survival of 13 months (range, 4-20 months). Median overall survival was significantly longer than the cohort group (19.0 vs 3.0 months; p = .013). CONCLUSION: Salvage surgery in patients with carcinoma of the cervical esophagus postesophagectomy is feasible with significantly prolonged survival.

Whole-organ histopathological study of recurrent nasopharyngeal carcinoma.

OBJECTIVES/HYPOTHESIS: To study the histopathological features of recurrent nasopharyngeal carcinoma and the accuracy of preoperative magnetic resonance imaging (MRI). STUDY DESIGN: Prospective. METHODS: Whole-organ study of nasopharyngectomy specimens. RESULTS: Between 2006 and 2009, 50 specimens were obtained after maxillary swing nasopharyngectomy and sent for whole-organ study. The tumors arose from the fossa of Rosenmüller (68%), posterior wall (18%), or roof of the nasopharynx (14%), and the majority (72%) took the form of an ulcerative tumor. The T-classifications of the recurrent tumors were: T1, 24%; T2, 48%; and T3, 28%. All the tumors appeared as islands of cancer cells separated by lymphoplasmacytic infiltrate and fibrosis. The tumor size measured by MRI correlated closely with that measured histologically, especially for the depth of invasion and parapharyngeal extension. For tumors with parapharyngeal extension, removal of the pharyngobasilar fascia was essential to ensure a clear margin on the surface of the petrosal internal carotid artery. None of the tumors showed invasion of the Eustachian tube. CONCLUSIONS: Contrast MRI is accurate in assessing the local extent of recurrent nasopharyngeal carcinoma. During nasopharyngectomy, a radial resection margin of 15 mm should be taken with the underlying medial pterygoid muscle. For tumors with parapharyngeal extension, the pharyngobasilar fascia should be resected en bloc with the specimen. LEVEL OF EVIDENCE: N/A.

Olfactory neuroblastoma: a 35-year experience and suggested follow-up protocol.

OBJECTIVES/HYPOTHESIS: To validate a follow-up protocol based on the long-term outcomes and recurrence rates in patients who have undergone surgical treatment for olfactory neuroblastoma. METHODS: A prospective review of all patients treated for olfactory neuroblastoma at our institution over a 35-year period. RESULTS: Ninety-five patients were treated from 1978 to 2013, with craniofacial (65 patients) or endoscopic resection (30 patients). Duration of follow-up ranged from 1 to 309 months (mean, 88.66 months). Fifty-six patients were alive and well, and 13 were alive with recurrent disease. Twenty-one patients had died of disease, and three had died of intercurrent disease. Overall survival was 83.4% at 5 years and 76.1% at 10 years. Disease-free survival at 5 years was 80% and at 10 years was 62.8%. A Cox regression analysis showed orbital extension and intracranial involvement to be significant independent factors affecting outcome. Local and regional recurrence occurred after an average of 49 months but with a range of 3 to 233 months. CONCLUSIONS: In our series, olfactory neuroblastoma most commonly recurred within the first 4 years but can recur very late, after 19.4 years in one case. There is currently no universally accepted follow-up regime, but even late recurrence is eminently treatable. We therefore propose a protocol for lifelong follow-up with both clinical examination and serial imaging, including the neck and entire intracranial compartment. LEVEL OF EVIDENCE: 4.

Cervical spine complications after treatment of nasopharyngeal carcinoma.

PURPOSE: Radiotherapy has been the mainstay treatment for nasopharyngeal carcinoma (NPC) and has achieved good disease control. However, irradiation is associated with potential complications such as osteoradionecrosis (ORN) and infection. There is sparse description in the literature of such complications and how they are best managed. The objectives of the study are: (1) to describe the complications at the cervical spine after surgical and radiotherapy treatment for NPC (2) to identify key principles in the diagnosis and treatment of these complications. METHODS: A retrospective review of all patients with cervical spine complications after radiation treatment and surgery for NPC treated in a tertiary referral center, since 1990. RESULTS: Fourteen patients with cervical spine ORN and infections were found with an average duration to diagnosis of 8.6 years. All 14 patients had mucosal and deep biopsies and none had tumor recurrence. Four patients had ORN, eight had osteomyelitis and two patients had both ORN and osteomyelitis. CONCLUSIONS: Radiotherapy complications usually have delayed and subtle presentations. ORN progresses slowly and can often be treated conservatively. Infections should be treated aggressively with surgical debridement and the results are generally good. Patients should be regularly followed-up with transoral examination to assess the integrity of the posterior pharyngeal wall and imaging to assess for ORN. Pharyngeal defects raise concern for cervical spine infections. Coverage of pharyngeal defects in these patients is important to prevent recurrent infection.

Long-term hearing results and otological complications of nasopharyngeal carcinoma patients: comparison between treatment with conventional two-dimensional radiotherapy and intensity-modulated radiotherapy.

OBJECTIVE: To assess the long-term audiological outcome and otological complications of nasopharyngeal carcinoma patients who have received intensity-modulated radiotherapy (IMRT) versus conventional two-dimensional radiotherapy (2 DRT). STUDY DESIGN: Prospective study on the audiological outcome and otological complications 5-9 years after radiotherapy. METHODOLOGY: Patients had pure-tone audiogram before radiotherapy and 5 years after radiotherapy. Otological examination was performed 5-9 years after radiotherapy by an otolaryngologist. RESULTS: There is a significant deterioration of the hearing threshold 5 years after radiotherapy but there is no statistically significant difference in the deterioration of hearing between IMRT and 2 DRT. Six patients in the 2 DRT group and 1 patient in the IMRT group had osteoradionecrosis of the external auditory canal (p = 0.042). CONCLUSION: There are fewer incidences of osteoradionecrosis of the external auditory canal in patients treated with IMRT. There is no difference in bone conduction threshold in patients treated with IMRT or 2 DRT.

Combined transnasal endoscopic and transoral robotic resection of recurrent nasopharyngeal carcinoma.

BACKGROUND: We report a case of resecting a recurrent nasopharyngeal carcinoma using a combined technique of transoral robotic surgery and transnasal endoscopic surgery. METHOD: A small recurrent tumor was located in the roof of the nasopharynx. The inferior part of the resection was performed with a da Vinci surgical robot transorally after splitting the soft palate to expose the nasopharynx. The superior part of the resection, including removal of the anterior wall and floor of the sphenoid was performed transnasally under endoscopic vision. RESULTS: The tumor was removed enbloc with the sphenoid sinus wall with clear resection margin. Recovery was uneventful and the patient had minimal morbidity from the operation. CONCLUSION: For minimally invasive surgery to resect recurrent nasopharyngeal carcinoma, transnasal endoscopic surgery and transoral robotic surgery compliments each other, allowing improved resection.

Nasopharyngectomy for locally advanced recurrent nasopharyngeal carcinoma: exploring the limits.

BACKGROUND: The purpose of this study was to present the outcome of nasopharyngectomy for locally advanced recurrent nasopharyngeal carcinoma (NPC). METHODS: Between 2000 and 2010, patients with locally advanced recurrent NPC were recruited. Surgical outcomes were analyzed retrospectively. RESULTS: Among the 22 patients recruited, all had extended resections via the maxillary swing approach, resulting in exposure of the petrosal part of the internal carotid artery (ICA). One patient required craniofacial approach for tumor removal. The curative resection rate was 81.8%. Free flap reconstruction was performed in all cases. The mean follow-up period was 38.8 months. All patients survived. Although 1 patient developed local and systemic tumor recurrence, the rest of the patients remained disease free. There was no carotid blowout or osteoradionecrosis of the skull base. CONCLUSION: Curative resections can be achieved for locally advanced recurrent NPC with good outcome. Microvascular free flap reconstruction is crucial to prevent carotid artery blowout and osteoradionecrosis of the skull base.

Review of salivary gland neoplasms.

Salivary gland tumours most often present as painless enlarging masses. Most are located in the parotid glands and most are benign. The principal hurdle in their management lies in the difficulty in distinguishing benign from malignant tumours. Investigations such as fine needle aspiration cytology and MRI scans provide some useful information, but most cases will require surgical excision as a means of coming to a definitive diagnosis. Benign tumours and early low-grade malignancies can be adequately treated with surgery alone, while more advanced and high-grade tumours with regional lymph node metastasis will require postoperative radiotherapy. The role of chemotherapy remains largely palliative. This paper highlights some of the more important aspects in the management of salivary gland tumours.

Craniofacial surgery for esthesioneuroblastoma: report of an international collaborative study.

Introduction Impact of treatment and prognostic indicators of outcome are relatively ill-defined in esthesioneuroblastomas (ENB) because of the rarity of these tumors. This study was undertaken to assess the impact of craniofacial resection (CFR) on outcome of ENB. Patients and Methods Data on 151 patients who underwent CFR for ENB were collected from 17 institutions that participated in an international collaborative study. Patient, tumor, treatment, and outcome data were collected by questionnaires and variables were analyzed for prognostic impact on overall, disease-specific and recurrence-free survival. The majority of tumors were staged Kadish stage C (116 or 77%). Overall, 90 patients (60%) had received treatment before CFR, radiation therapy in 51 (34%), and chemotherapy in 23 (15%). The margins of surgical resection were reported positive in 23 (15%) patients. Adjuvant postoperative radiation therapy was used in 51 (34%) and chemotherapy in 9 (6%) patients. Results Treatment-related complications were reported in 49 (32%) patients. With a median follow-up of 56 months, the 5-year overall, disease-specific, and recurrence-free survival rates were 78, 83, and 64%, respectively. Intracranial extension of the disease and positive surgical margins were independent predictors of worse overall, disease-specific, and recurrence-free survival on multivariate analysis. Conclusion This collaborative study of patients treated at various institutions across the world demonstrates the efficacy of CFR for ENB. Intracranial extension of disease and complete surgical excision were independent prognostic predictors of outcome.

Recurrent nasopharyngeal carcinoma: surgical salvage vs. additional chemoradiation.

PURPOSE OF REVIEW: The primary treatment modality of nasopharyngeal carcinoma (NPC) is radiation or chemoradiation. With the application of conformal radiation and appropriate chemotherapeutic agents, there was marked improvement in the outcome. Despite this, a small number of patients still develop residual or recurrent disease either in the neck or at the primary site. In recent years there are many developments in the disciplines of surgery, radiation and medical oncology which are applicable for the management of residual or recurrent NPC. It is timely to review the applicability and efficacy of the various therapeutic options. RECENT FINDINGS: The theme of the literature review included the management of these recurrent or residual diseases in the neck or nasopharynx with open or endoscopic or robot-assisted surgical approaches. The application of radiation techniques such as intensity modulated radiotherapy, stereotactic radiation and brachytherapy was also included. The use of chemotherapy and targeted agents is also reviewed. SUMMARY: In general, the size, extent and location of the residual or recurrent NPC together with the biological behaviour of the tumour determine the optimal therapy. The surgical and clinical oncological expertise applied optimally will give the best outcome.

Surgical salvage of persistent or recurrent nasopharyngeal carcinoma with maxillary swing approach - Critical appraisal after 2 decades.

BACKGROUND: The purpose of this study was to report on our experience on salvage nasopharyngectomy using the maxillary swing approach for persistent or recurrent nasopharyngeal carcinoma after primary treatment. METHODS: Over the past 2 decades, we have performed salvage nasopharyngectomies for 246 patients. Thirty-seven patients (15%) had persistent disease and 209 (85%) had recurrent tumors. RESULTS: All patients survived the operation with minimal morbidity. Negative resection margins were achieved in 191 patients (78%), and 55 patients (22%) had microscopic residual disease. The median follow-up was 38 months. The 5-year actuarial control of disease in the nasopharynx was 74%. The 5-year disease-free survival was 56%. Cox regression model identified the negative resection margin and the size of the tumor as 2 independent factors that affected local control of disease and survival. CONCLUSION: Maxillary swing nasopharyngectomy is an effective salvage procedure for a small, persistent, or recurrent tumor in the nasopharynx after primary therapy.

Current management of cervical esophageal cancer.

BACKGROUND: Pharyngo-laryngo-esophagectomy (PLE) has been regarded as a standard treatment for cervical esophageal cancer, but the morbidity and mortality rates associated with PLE are substantial. Chemoradiation (CTRT) is widely used to treat esophageal cancer; however, its role in managing cervical esophageal cancer has not been fully elucidated. It was hypothesized that up-front CTRT could be an effective alternative treatment option to PLE. The purpose of this study was to compare the outcomes of patients with cervical esophageal cancer treated with these two methods. METHODS: Patients with cervical esophageal cancer from 1995 to 2008 were studied. Three main groups were identified: those treated with PLE, those managed with up-front concurrent chemoradiation, and those not suitable for either PLE or chemoradiation but to whom palliative treatment was offered. The demographics, management strategies, and outcomes of these patients were studied and analyzed. RESULTS: A total of 107 patients were studied: 87 (81.3%) were men, and the median age was 64 years (range 17-92 years). There were 62 patients who underwent PLE as the primary treatment, 21 had up-front chemoradiation, and the others had palliative treatment. In the PLE group, curative resection was achieved in 37 (59.7%) patients, 20 of whom had either adjuvant chemoradiation or radiotherapy. The hospital mortality rate was 7.1%. In the chemoradiation group, 10 (47.6%) had tumor down-staging, 6 of whom achieved a clinically complete response. Among the 11 patients with poor response, 5 required salvage PLE for palliation. Chemoradiation-associated morbidities included oral mucositis, bilateral vocal cord palsy, esophageal stricture, carotid artery blowout, and permanent hypothyroidism and hypoparathyroidism. The median survival durations of patients in the PLE and chemoradiation groups were 20 and 25 months respectively (P = 0.39). CONCLUSIONS: Up-front chemoradiation can be an alternative therapeutic strategy to PLE. However, this method is not without drawbacks. A significant proportion also requires salvage surgery. Both PLE and chemoradiation have significant curative as well as palliative role in the management of cervical esophageal cancer and treatment should be individualized.

Transoral robotic resection of recurrent nasopharyngeal carcinoma.

Transoral robotic nasopharyngectomy was carried out for a patient who developed recurrent nasopharyngeal cancer after radiotherapy. The tumor in the left lateral wall of the nasopharynx was exposed after splitting the soft palate and a curative resection, including the medial crus of the eustachian tube was carried out under the three-dimensional 0° camera. The operative procedure was uncomplicated, blood loss was minimal and the patient recovered smoothly. The camera of the surgical robot provided superb visualization of the operative field and the maneuverability of the robotic arms with the Endowrist design allowed adequate tumor extirpation. The morbidity associated with the procedure was minimal, and this surgical procedure can be applied for resection of small and favorably located residual or recurrent nasopharyngeal cancer or other appropriate pathologies in the region. Laryngoscope, 2010.

Current management strategy of nasopharyngeal carcinoma.

Nasopharyngeal carcinoma is an unique head and neck cancer. It is common among the southern Chinese and is closely associated with the Epstein Barr virus (EBV). To diagnose the disease in its early stage is infrequent as the symptoms are usually trivial and patients only present in late stages. Testing the blood for elevated EBV DNA has now become a screening test for the high risk group of patients, aiming to diagnose the disease in its early stages. Imaging studies, positron emission tomography scans in addition to clinical examination provide information on the extent of the disease. The confirmation of the disease still depends on endoscopic examination and biopsy. Radiotherapy with or without chemotherapy has been the primary treatment modality. The application of intensity modulated radiotherapy and the use of concomitant chemoradiation have improved the control of nasopharyngeal carcinoma together with the reduction of long term side effects. The early detection of residual or recurrence tumor in the neck or at the primary site has allowed delivery of salvage treatment. The choice of the optimal surgical salvage, either for neck disease or primary tumor depends on the extent of the residual or recurrent disease. The outcome of these patients have improved with the application of the appropriate surgical salvage.